Endometriosis is one of the most frequent diseases of women in their reproductive lifespan. It is characterized by the presence of endometrial tissue outside the uterine cavity, consisting histological of glands and stroma. The anatomical sites most often affected are the ovaries, uterosacral ligaments, pelvic peritoneum, rectovaginal septum, cervix, vagina, the fallopian tubes and vulva.
Endometriosis is considered to be a benign disease, but endometriotic lesions occasionally become malignant. As in other kind of malignancies, the development of endometriosis-derived neoplasms is due to concurrent events, involving alterations in growth factors and/or oncogenes regulation (Kyama et al. 2003). Further, endometriosis is considered as a major cause of infertility (Giudice et al. 2004).
The current treatment of endometriosis consists of hormonal therapy and/or surgery. Hormonal therapies include high dose of progestogens, progestins, oral contraceptives (combinations of estrogen and progesterone), Danazol (an androgenic derivative of ethisterone) and more recently GnRH agonists. These hormonal therapies are effective on pelvic pain and may induce an objective regression of lesions, but have several caveats. Estrogen may stimulate and cause proliferation of endometriotic tissue since it may be unable to respond to progesterone (Dawood et al, 1993). Progestational agents can provoke irregular bleeding along with depression, weight gain, and fluid retention. Danazol can improve symptoms in approximately 66-100% of the patients suffering from pain, but recurrence rates after up to 4 years are approximately 40%-50%. Other drawbacks of Danazol therapy are weight gain and androgenic side effects. GnRH analogs are more potent and long acting than native GnRH, which act by removing the estrogenic stimulus for the growth of all estrogen sensitive tissues. Side effects of GnRH analogs are mainly secondary to the profound hypoestrogenemia, like decreased bone density, and recurrence rate are up to 50% after 5 years (Waller et al., 1993). Further complicating treatment is the observation that endometriotic lesions in many patients either are or become resistant to the effects of progesterone and/or progestins. (Bulun et al. 2006).
Surgical intervention can be conservative, if fertility is desired, or can lead to the removal of the uterus, tubes and ovaries in case of severe disease. In any case, even limited surgical treatment leads to a significant decrease in fertility.
Although endometriosis stands as one of the most investigated disorders of gynecology, the current understanding of pathophysiology of the disease remains elusive. According to a favored theory, endometriotic lesions develop by eutopic endometrical cells leaving their primary site, possibly by retrograde menstruation, and implant at distant sites, followed by invasion of host tissue and proliferation. Furthermore, it appears that endometriosis is an invasive and metastasizing disease. Though endometriotic cells proliferate to a certain extent, they are not neoplastic as typically found in carcinomas. Apparently, endometriotic cells become senescent, apoptotic and necrotic. Inflammatory responses that are induced or accompanied by lesion formation finally lead to fibrosis and the formation of scars.
It has been speculated whether tumor or metastasis suppressor genes (e.g. E-cadherin) are associated with endometriosis. E-cadherin is a metastasis suppressor molecule, its down-regulation or functional inactivation is a prerequisite for invasion and metastasis (Frixen et al, 1991). Zeitvogel et al. (2001) showed that E-cadherin is absent and N-cadherin is present in endometriotic cells. N-cadherin is suggested to be the path-finding molecule that allows cells to be invasive and migratory in normal development and pathological processes.
Recently, it has been demonstrated that recombinant human TNFα binding protein (rh-TBP-1) is effective in reducing the size and severity of endometriotic lesions in an experimental model of endometriosis (D'Hooghe et al. 2001). These results were the first to demonstrate that an anti-inflammatory molecule (r-hTBP-1) that targeted the TNFα-pathway provided effective medical treatment for patients with endometriosis that did not inhibit ovulation.
Yoshino et al. (2004) showed that mitogen-activated protein kinases (MAPKs), which are intracellular signal transducers, mediate some of the effects exerted by proinflammatory cytokines. Yoshino et al. further showed the presence of MAPks (e.g. ERK, JNK and p38) in endometriotic cells and their phosphorylation under inflammatory stimulation by IL-1β, TNFα and H2O2. MAPKs are serine/threonine kinases that are activated by dual phosphorylation on threonine and tyrosine residues. In mammalian cells, there are at least three separate but parallel pathways that convey information generated by extra-cellular stimuli to the MAPKs. Said pathways consist of kinase cascades leading to activation of the ERKs (extracellular regulated kinases), the JNKs (c-Jun N-terminal kinases), and the p38/CSBP kinases (Dent et al 2003). c-Jun is a protein that forms homodimers and heterodimers (with e.g. c-Fos) to produce the transactivating complex AP-1, which is required for the activation of many genes (e.g. matrix metalloproteinases) involved in the inflammatory response.
The invention described herein clearly shows the unexpected result that inhibiting JNK, by means of a JNK inhibitor, reduces endometriotic-like foci in a rat and in nude mouse experimental models. A rat model also demonstrates that such effect is obtained by inhibiting the Natural Killer cells activity associated with the disease as well as reducing several cytokines found elevated in endometriosis. These cytokines are among others, IL-6 and IL-8 that are suggested to play a key role (Barcz et al., 2000). The JNK inhibitors described herein restore the sensitivity of endometrial cells and lesions to progesterone. Furthermore, the JNK inhibitors described herein used in combination with a SPRM or progestin can prevent re-establishment of endometriosis. The reduction of endometriotic lesions using JNK inhibitors can also improve fertility rates, since the normalization of genital structure has a positive effect on the implantation rate.
Several small molecules have been proposed as modulators of the JNK pathway. Aryl-oxindole derivatives of respectively the generic formula (A) (WO 00/35909; WO 00/35906; WO 00/35920) and formula (B) (WO 00/64872) have been developed for the treatment of neurodegenerative diseases, inflammation and solid tumors for formula (A) and for the treatment of a broad range of disorders including, neurodegenerative diseases, inflammatory and autoimmune diseases, cardiovascular and bone disorders for formula (B).
Pyrazoloanthrones derivatives of formula (C) have been reported to inhibit JNK for the treatment of neurological degenerative diseases, inflammatory and autoimmune disorders as well as cardiovascular pathologies (WO 01/12609).

Tetrahydro-pyrimidine derivatives of formula (D) were reported to be JNK inhibitors useful in the treatment of a wide range of diseases including neurodegenerative diseases, inflammatory and autoimmune disorders, cardiac and destructive bone pathologies (WO 00/75118).

Other heterocyclic compounds of formula (E) have been proposed to inhibit protein kinases and especially c-un-N-Terminal kinases (WO 01/12621) for treating “JNK-mediated conditions” including proliferative diseases, neurodegenerative disorders, inflammatory and autoimmune disorders.

Benzazoles derivatives such as represented by formula (F) (WO 01/47920) have been described as modulators of the JNK pathway for the treatment of neuronal disorders, autoimmune diseases, cancers and cardiovascular diseases.

Several sulfonamide derivatives of formula (G) (WO 01/23378), sulfonyl amino acid derivatives of formula (H) (WO 01/23379) and sulfonyl hydrazide derivatives of formula (J) (WO 01/23382), were also developed to inhibit JNKs for treating neurodegenerative diseases, auto-immune disorders, cancers and cardiovascular diseases.
